Latest reports, citations, and penalties from CMS data
During five separate observations between March 24-27, inspectors found the resident reclined in the Broda chair either at the nursing station or in her room....
## Medical Implications of the Transfer Accident The resident's medical history made this incident particularly dangerous....
Inspectors found that Heritage Park Care Center failed to meet these basic care requirements for vulnerable residents....
When questioned about cleaning protocols, the nurse stated she sanitized the glucometer only at the beginning and end of her shift, not between residents....
The resident clearly communicated his wishes during the inspection, stating **he wanted to be resuscitated and wanted to be Full Code**....
The resident, who had been admitted less than 24 hours earlier, was lying in bed when the aide attempted to transfer her....
Four residents specifically identified in the report experienced gaps in critical care that could have resulted in severe health consequences....
The resident received Entresto and carvedilol despite blood pressure readings as low as 103/74 and 106/46....
This represents a fundamental breakdown in the facility's internal quality control mechanisms designed to prevent medical errors and ensure resident safety....
These medications are specifically designed as extended-release formulations that should never be crushed or opened....
Inspectors identified issues with how the facility handled medication supervision and self-administration protocols....
Dietary Aide #23 was observed rinsing dirty dishes, washing plates and trays while wearing gloves and an apron that contacted contaminated surfaces....
The resident, identified as R1 in the inspection report, subsequently died at the hospital after sustaining injuries from the fall....
The errors involved residents receiving incorrect medications and missing prescribed treatments....
The exposed outlet was positioned within arm's reach of the bed, creating potential shock and electrocution risks for the vulnerable resident....
However, inspection records show **the facility documented no response to either recommendation**....
**The therapeutic window between effective treatment and dangerous bleeding is narrow**, making precise dosing critical for patient safety....
The violations included potentially life-threatening incidents that could have resulted in serious harm to diabetic residents....
All three staff members provided the same concerning response: they would leave the bleeding resident alone to seek nursing assistance....
Two residents - both diagnosed with severe dementia and documented as daily wanderers - left the facility grounds undetected....